Deep Lamellar Keratoplasty Combined with Cataract Surgery

SURGICAL TECHNIQUE Deep Lamellar Keratoplasty Combined With Cataract Surgery

Marc C. Muraine, MD; Ame´lie Collet, MD; Ge´rard Brasseur, MD, PhD

e used a surgical technique that combines deep lamellar keratoplasty, phacoemulsification, and intraocular lens implantation for treating patients with cataract and corneal stromal disease. Deep lamellar dissection of the cornea was first performed with viscoelastic substances (hyaluronate sodium) until the highly Wtransparent Descemet membrane solely remained. We then created a short corneal tunnel to perform phacoemulsification with low vacuum and intraocular lens implantation. The resilience of the Descemet membrane ensured excellent viewing of the whole anterior chamber as well as the surgical conditions of a closed system. At the end of surgery, a full-thickness donor button was sutured into the recipient bed after its Descemet membrane was stripped. This technique was ef- fective in these 4 patients with cataract and dense corneal opacity. Arch Ophthalmol. 2002;120:812-815 Patients who are treated for cataract asso- We describe herein a technique that ciated with corneal disease classically un- combines deep lamellar keratoplasty and dergo a 3-phase surgical procedure (pen- cataract surgery. We were thus able to dem- etrating keratoplasty, extracapsular cataract onstrate that the resilience of the bared Des- extraction, and then intraocular lens cemet membrane could withstand all steps implantation). However, implementing that of standard phacoemulsification in pa- technique poses a number of technical tients who had cataract associated with cor- problems or difficulties, including in par- neal stromal disease. That option is dou- ticular a nonnegligible number of compli- bly interesting in that patients, on the one cations during capsulorrhexis. The lack of hand, benefit from optimal operative con- pressure in the anterior chamber, inher- ditions of cataract closed surgery and, on the ent in this open surgery procedure, can- other hand, receive the benefit of lamellar not balance the vitreous pressure; hence, surgery, ie, no rejection and sustainable there is a much higher risk of radial cap- long-term resilience of the ocular globe. sular cracks. To eliminate that risk, most authors recommend performing capsulor- METHODS rhexis, or even phacoemulsification, before trephination whenever corneal trans- The operation was performed with the parency permits,1-4 or using a temporary patient under peribulbar anesthesia keratoprosthesis5 or corneal graft6 when (Figure 1 and Figure 2). After air was corneal opacity is too great. injected into the anterior chamber, a 30- Corneal surgery has also acquired, in gauge needle connected to a syringe full recent years, a new surgical technique to of viscoelastic substance was inserted into treat corneal opacities: deep lamellar kera- the corneal stroma at the midperiphery toplasty.7-9 In that process, the corneal level. When the needle reached the deep stroma needs to be fully and entirely ex- corneal layers, the viscoelastic substance cised to leave only the bare Descemet was injected to separate the posterior membrane; then the stroma is replaced by stroma from the Descemet membrane. a full-thickness graft. When viscodissection was complete, the From the Department of Ophthalmology, Hoˆpital Charles Nicolle, Rouen, France. cornea was trephinated over a 7.5-mm di-

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C D

E F

Figure 1. Schematic development of combined surgery. A, Deep lamellar keratoplasty is performed with viscodissection. Finally, only the Descemet membrane remains. Arrow indicates the direction of the ablation of the corneal button. B, Capsulorrhexis, hydrodissection, and phacoemulsification are performed through a corneal tunnel. C, After implantation of an G H intraocular lens, a corneal graft is stitched on top of the remaining Descemet membrane. Arrow indicates the direction of the placement of the corneal graft.

ameter and 1.2-mm depth. The corneal stroma thus isolated from the Descemet membrane could then be easily excised with scissors. When deep stromal layers persisted, they also were separated from the Des- Figure 2. Development of combined surgery. A, After air insufflation into the anterior chamber, viscoelastic substance is injected into the stroma to separate the posterior stroma from the Descemet cemet membrane by viscodissec- membrane (patient 1). B, After trephination and excision of the stroma, only the highly transparent tion and excised. Ultimately, only the Descemet membrane remains (patient 1). C, Corneal incision (patient 1). D, Capsulorrhexis (patient 2). fully transparent Descemet mem- E, Phacoemulsification is performed behind the Descemet membrane with very good visibility (patient 1). F and G, Implantation of intraocular lens through the limbic incision (patient 2 with forceps [F], patient 3 brane must remain, ensuring per- with injector [G]). H, A corneal graft is stitched with 10-0 nylon (appearance 2 months fect visualization of the whole an- postoperatively in patient 2). terior chamber while maintaining its tightness. As a matter of safety, we The capsular bag was then re- a triangular sponge. The graft was coated the Descemet membrane with inflated with the viscoelastic sub- then sutured with 10-0 nylon. viscoelastic substance. stance and implantation was per- A 3.2-mm corneal incision was formed in the capsular bag. The RESULTS then performed, care being taken to corneal incision was not sutured. penetrate the anterior chamber Finally, the Descemet mem- Four patients were operated on with within trephination limits, then a vis- brane was rinsed and cleared of any this technique, and 3 to 12 months coelastic substance was injected into viscoelastic substance, so as to en- of follow-up was available. Pa- the anterior chamber. Capsulor- sure correct positioning of the cor- tients’ preoperative and postopera- rhexis was performed with forceps, neal graft. That graft was prepared tive data are shown in the Table. and hydrodissection and phaco- from a whole cornea trephinated to There were no complications in emulsification were carried out ac- 7.5 mm in diameter in which the en- 3 patients. In all cases the “divide and cording to the usual technique. dothelium was slowly destroyed with conquer” technique was deemed

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 This is the first demonstration, to our Clinical Characteristics of 4 Patients* knowledge, that the resilience of the Descemet membrane enables it to Visual Acuity Patient No./ Original Corneal Follow-up, withstand the operative duration of Sex/Age, y Disease mo Preoperative Postoperative phacoemulsification under visibility 1/M/61 HZO 6 HM 20/50 conditions identical to those of a per- 2/M/63 HSV keratitis 12 CF 20/30 fectly clear cornea. This proves that 3/F/41 HSV keratitis 4 CF 20/40 patients eligible for deep lamellar 4/M/67 Viral nonherpetic keratitis 3 CF 20/40 keratoplasty can also be operated on for cataract at the same time and thus *HZO indicates herpes zoster ophthalmicus; HSV, herpes simplex virus; CF, counting fingers; keep their endothelium. Such a sur- and HM, hand movements. gical procedure permits operating on cataract in a “closed system” and re- preferable and safer, and used rather density and increased globular re- ducing the previously mentioned low aspiration rates to prevent any silience to trauma.7-9 perioperative risks. risk of the anterior chamber collaps- However, a number of pa- However, a number of precau- ing. In 1 case, the corneal incision tients eligible for deep lamellar kera- tions need to be observed. First, the reached the trephination limit, in- toplasty have cataract disease that phacoemulsification probe’s cor- ducing a permanent leak on that site. needs to be treated surgically to neal tunnel must not be too long, so Fortunately, the Descemet aper- restore acceptable eyesight. When as to prevent leaks at the Descemet ture was slightly posterior in rela- 2 surgical procedures are contem- membrane level, which would jeop- tion to trephination; the latter was plated within the same operative ses- ardize constant pressure in the ante- not enlarged and the operation could sion, surgeons classically perform a rior chamber. It is also recom- be carried out to completion. triple procedure associating penetrat- mended not to perform corneal Postoperatively, the cornea being keratoplasty, extracapsular cata- trephination exceeding 8 mm in di- came clear in all cases. Despite a his- ract extraction, and intraocular lens ameter, with 7.5 mm being fully ad- tory of herpetic keratitis and neovas- implantation, probably because they equate. Too-high aspiration rates are cularization, none of the 4 patients fear excessive fragility of the bare Des- also to be avoided, to prevent ante- manifested any signs of rejection dur- cemet membrane. Patients then lose rior chamber collapse, in particular ing the postoperative period. all the benefits of deep lamellar kera- at the end of each lens fragment as- toplasty. piration. COMMENT Operative conditions, how- This study demonstrates that ever, are not optimal when lens sur- observing those recommendations Deep lamellar keratoplasty is a deli- gery is performed openly, because will make it possible to operate on cate surgical technique, but in re- the posterior pressure is not being patients with corneal opacity asso- cent years interest in it has in- balanced by the tightness of the an- ciated with cataract under very ac- creased, when corneal disease does terior chamber. The most frequent ceptable conditions. The patients not affect the endothelial layer.7-9 The complications include incomplete will experience faster eyesight re- aim of the operation is to separate capsulorrhexis, incomplete aspira- covery than with 2-step surgery and the Descemet membrane from the tion-irrigation of the cortex, uncer- yet retain all the benefit of lamellar stroma before corneal trephina- tain placement of the intraocular keratoplasty. tion. The graft can be performed only lens, posterior capsule rupture, cho- when all stroma remainders have roidal effusion, and even expulsive Submitted for publication November 1 been excised from the front of the hemorrhage. Most authors there- 30, 2001; final revision received Janu- Descemet membrane. The graft is fore recommend performing capsu- ary 14, 2002; accepted January 25, trephinated from a donor’s whole lorrhexis or even phacoemulsifica- 2002. cornea. The endothelial side of the tion before trephination whenever We thank Philip Rousseau- 1-4 donor’s cornea is wiped with a cot- corneal transparency permits or us- Cunningham for his advice in editing 5 ton swab for easy ablation of the Des- ing a temporary keratoprosthesis or the manuscript. 6 cemet membrane, leaving a per- corneal graft if corneal opacity is too Corresponding author and re- fectly smooth surface on the stromal pronounced. prints: Marc C. Muraine, MD, De- side. The result is that no scar is Descemet membrane is a con- partment of Ophthalmology, Hoˆpital formed between the host’s and the densation of collagen IV and lami- Charles Nicolle, Boulevard Gam- donor’s corneas. The visual results, nin that is 7 to 10 µm thick. Desce- betta, 76031 Rouen, France (e-mail: therefore, were as good as those from met membrane is tough and resistant [email protected]). transfixing keratoplasty.10 The ad- to enzymatic degradation. In certain vantages of deep lamellar kerato- corneal ulcerations, such as Mooren plasty as a treatment for corneal ulcer or bacterial keratitis, Descemet REFERENCES stroma disease are clear. Unlike pen- membrane remains intact and pro- etrating keratoplasty, it is exempt trudes as a descemetocele that is 1. Malbran ES, Malbran E, Buonsanti J, Adrogue E. Closed-system phacoemulsification and posterior from rejection risks, and it pre- caused by intraocular pressure after chamber implant combined with penetrating kera- serves high long-term endothelial dissolution of the overlying stroma.11 toplasty. Ophthalmic Surg. 1993;24:403-406.

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 2. Robin H, Hannouche D, Hoang-Xuan T. Triple pro- procedure using a temporary keratoprosthesis for tion. Arch Ophthalmol. 1999;117:1561-1565. cedure with phacoemulsification prior to graft- closed-system, small-incision cataract surgery. 9. Melles GR, Remeijer L, Geerards AJ, Beekhuis WH. ing [in French]. J Fr Ophtalmol. 1997;20:701- J Cataract Refract Surg. 1990;16:230-234. A quick surgical technique for deep, anterior la- 703. 6. Nardi M, Giudice V, Marabotti A, Alfieri E, Rizzo mellar keratoplasty using visco-dissection. Cornea. 3. Baca LS, Epstein RJ. Closed-chamber capsu- S. Temporary graft for closed-system cataract sur- 2000;19:427-432. lorhexis for cataract extraction combined with pen- gery during corneal triple procedures. J Cataract 10. Panda A, Bageshwar LM, Ray M, Singh JP, Ku- etrating keratoplasty. J Cataract Refract Surg. Refract Surg. 2001;27:1172-1175. mar A. Deep lamellar keratoplasty versus pen- 1998;24:581-584. 7. Sugita J, Kondo J. Deep lamellar keratoplasty with etrating keratoplasty for corneal lesions. Cornea. 4. Caporossi A, Traversi C, Simi C, Tosi GM. Closed- complete removal of pathological stroma for vi- 1999;18:172-175. system and open-sky capsulorhexis for combined sion improvement. Br J Ophthalmol. 1997;81: 11. Nishida T. Basic science: cornea. In: Krachmer JH, cataract extraction and corneal transplantation. 184-188. Mannis MJ, Holland EJ, eds. Cornea, Volume I: Fun- J Cataract Refract Surg. 2001;27:990-993. 8. Manche EE, Holland GN, Maloney RK. Deep la- damentals of Cornea and External Disease. St Louis, 5. Menapace R, Skorpik C, Grasl M. Modified triple mellar keratoplasty using viscoelastic dissec Mo: Mosby–Year Book Co Inc; 1997:3-27.

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